Pectus Excavatum

Pectus excavatum (PE) is a condition in which a person's breastbone is sunken into his or her chest. In severe cases, pectus excavatum can look as if the center of the chest has been scooped out, leaving a deep dent. PE accounts for more than 90% of congenital chest wall deformities and can be more than a cosmetic deformity.

Severe deformities can cause cardiopulmonary limitations and symptoms may increase as patients get older. Improvement in symptoms has been reported following surgery. These symptoms generally include:

• Progressive loss of endurance /exercise intolerance
  • Shortness of breath, fast heart rate and/or chest discomfort with exercise
  • Inability to keep up with peers
• Chest discomfort/pain with activity
• Palpitations (sensation of a strong, rapid or irregular heartbeat)
• Tachycardia (fast heartbeat)
• Psychological issues due to the deformity

If you are worried you or a family member have a pectus, our video "You think you have a pectus: the first step" reviews more information, including the process of obtaining a surgical recommendation.

Patients with suspected Pectus Excavatum can be referred to Mayo Clinic via their local provider, or can self-refer. Please note: it is important to have a local provider involved in your care before and after your pectus surgery. Your local provider team will be key to coordinating emergent issues that may arise during the post-op phase of your care.

Pectus Excavatum evaluation and surgery can be done at all 3 main Mayo Campuses: Phoenix, Arizona; Jacksonville, Florida; and Rochester, MN.

View Dr. Jaroszewski, surgeon at the Arizona location, performing a Pectus Excavatum Repair at Mayo Clinic

Registration

If you are choosing to self-refer and have not been seen at Mayo Clinic before you must first register as a patient. Registration is free and can be done online. Patients can also call for an appointment.

Establishing a medical record number is important to keep track of outside records and correspondence prior to meeting with a provider. ​The Appointment Office will contact you within 48-72 hours to complete your registration and provide you with a Medical Record Number for Mayo Clinic and schedule a consultation.

Insurance

You are encouraged to check with your insurance company to verify that Mayo Clinic is within your network. ​Billing and Insurance at Mayo Clinic

Testing and Evaluation of your Pectus

For most patient with PE we recommend the following tests and evaluations will be completed in order to determine if surgery is right for you.

• CT or MRI of the chest completed with the pectus protocol
  • Haller index
  • Severity of the deformity
  • Length of the deformity
  • Cardiac compression and/or displacement
  • Sternal rotation
• Echocardiogram
• Electrocardiogram
• Cardiopulmonary exercise (VO2 test)

Surgical repair recommendations are based on several factors and every patient is a unique individual. Some of the most common finding for surgical indication includes:

• Haller index greater than 3.25 or correction index >20%
• Cardiac compression or shift of heart into the left chest
• Cardiopulmonary function showing impairment due to the PE

Surgical Options

There are a number of techniques to repair your pectus excavatum. Learn more about the techniques used to repair pectus.

Primary Pectus Repair: a minimally invasive procedure that involves using forced sternal elevation and passage under the breast bone by camera view 2 or more bards to elevate and support deformity in correct positions.

 

Hybrid Repair: more complicated or severely asymmetric repairs may require a hybrid approach. In this approach a combined open repair with excision of abnormal cartilage and support pectus bar placement.

Travel

If you are traveling for surgery we recommend planning on spending 7-10 days on campus. Arrive 2 days before your surgery, plan on spending 2 days in the hospital, then give yourself 3 to 5 days to recover in the surrounding area prior to postoperative appointment, in case of any complications.

See the Surgery Packing List to help you prepare for your hospital stay.

Learn more about Getting Ready for Pectus Surgery

Day Before Surgery

The day before surgery you will receive a schedule for preoperative testing and a consultation to meet the pectus team. During the consultation, your provider will evaluate your defect and explain the surgical procedure, as well as answer any questions you may have. You will also receive the check-in time for your surgery.

Day of Surgery

The morning of surgery you will check-in at the hospital registration desk (Patient and Visitors Guide). You will then be directed/escorted to pre-operative room where you will be prepped for surgery. This includes placement of an IV line, meeting various members of the surgical team including anesthesia, and completion of health history and nursing assessments.

During the surgery, your family is encouraged to stay on Mayo Clinic's campus. When possible, they will be updated during the procedure. After the surgery is complete, a member of the surgical team will meet with your family and discuss the operation.

Immediately after surgery you will recover in the PACU (Post-Anesthesia Care Unit). Once appropriate, you will be transferred to your inpatient room, where your family can come and visit you.

Recovery

Recovering in the Hospital:

Most patients spend two days in the hospital after pectus surgery.

Learn more about your hospital stay

The Day of Surgery: 

The first night after surgery you will have a PCA (patient-controlled- analgesia) pump which allows a patient to administer IV pain medication when they need it. You will have a button to push and the pain medication will be given automatically.

You are encouraged to sit up and practice deep breathing exercises.

The ON-Q PainBuster Pain Pump works by continuously delivering local numbing anesthetic through a small catheter under the skin on either side of the chest. Your surgeon places this pump toward the end of your surgical procedure. This pump is commonly referred to as a "pain ball" due to the round rubber container that holds the numbing medication. The pump can be left in for up to 5 days. Most patients are ready for discharge by hospital day 3 and the ON-Q can stay in after you go home for a few more days (More information is provided in the Recovering at Home section).

The next morning:

You will be transitioned from the PCA pump to oral pain medications. These medications will be the same medication you will be sent home with.

Also starting the next morning you will begin to walk around the unit. There will be a continued emphasis on coughing and deep breathing. A chest x-ray will be done to document bar placement and your surgical team will stop in to monitor your recovery. Your chest tube may be removed on this day.

You should be up and out of bed (going to the bathroom counts) at least 3 times a day while you are recovering in the hospital. This low level of activity will reduce your risk for blood clots in your legs. Make sure to move your feet up and down in bed to stretch and flex your calf muscles.

The final day in the hospital: 

During this time patients are final transitions between IV medications to oral pain medications will occur, your chest tubes will be removed and you increasing your walking tolerance.

Recovering in Surrounding Area

You will be scheduled for a post-op visit with your surgeon's team after being discharged from the hospital. This will be coordinated with your stay if you are traveling a great distance to one of our 3 campus. On the day of your post-op appointment you will be scheduled for a chest x-ray. Please refer to your itinerary for follow-up appointments (can be found on your Patient Portal if not provided at the time of discharge). At the appointment you will be given scripts for pain medication, have your stitch removed from your chest tube site, and check your chest x-ray as well as answer any remaining questions.

Travel Card: You will also be given a travel card that states you have metal bars in you chest. Generally, the TSA will do a hand wand evaluation because of the metal implants.

MRI: The bars are compatible with most of the newer MRI machines (last 10 years). If you need to get a scan and there is any question, please contact your provider and we can forward your specification to the radiology team.

Recovering at Home

If you experience any emergent issues upon returning home please contact your local healthcare provider.

When should I call the doctor?

• When  your pain is unmanageable
• When you feel nauseated
• When you experience issues with your breathing
• If you are unable to urinate
• If you have not had a bowel movement in 48-hours and have tried the over-the-counter recommendations
• If your On-Q Pain Pump is leaking
• If you are having bleeding, increased redness or pus-like drainage on or around your incisions
• If you experience a fever of 101.5 degrees Fahrenheit
• If you are getting to sleepy or experiencing unexpected side-effects of medications

Bruising: Bruising is caused by a small amount of blood collecting underneath the surface of your skin. This blood may travel under the skin to other locations due to gravity. Please do not be alarmed if you notice bruising below your chest area or in your groin, this may happen.

Medication: You will be discharged with a 4-week supply of pain medications. These should be identical to what you were taking in the hospital. Please continue with your pain medications as directed by the pectus team. Every patient has a different tolerance level for pain but most are ready to start weaning off them within two weeks.

Please track your medication using the provided tracking log for a total of one week after being discharge from the hospital. The log will help make decision about medication dose changes and routines so remember to bring to your postoperative appointment for review.

Pectus-Medication-Log.pdf

Nausea: If you have a history of nausea/vomiting after anesthesia or with narcotic use, we will provide you with a prescription for ondansetron (Zofran) to take home with you. If you get nauseated or vomit with taking the pain medications, you may want to take one of these pills 3 times each day even if you aren't feeling sick to prevent the nausea from happening.

On-Q Pain Pump: If you are discharged from the hospital with the On-Q Pain Relief System, you will be given an estimated time when the medication will end. You can either have the catheters removed at your post-op visit, or remove them yourself. Removal is not painful and many patients are comfortable removing the catheters themselves. (Please refer to the On-Q Pain Relief System handout for further instructions)

Driving: You can drive when you are completely off pain medications and are healed to the point you can react quickly without causing pain or damage to your surgery site. Remember, you are considered under the influence for at least 8 hours of taking prescription pain medication.

Bathing/Water Exposure: You may shower as usual with warm, soapy water. Please pay attention to your incision sites and call if you see bleeding, increased redness or pus-like drainage. You are NOT allowed to use swimming pools, spas or tub baths until your incisions are fully healed.

Steri-Strips: Your steri-strips will gradually fall off within the first two weeks. Do not attempt to pull them off early.

Compression Garments: Some patients may be discharged with a white elastic binder for your torso. This binder is used to apply pressure to the surgical areas to decrease swelling to the area. The use of this binder may be comforting and should be used for at least two to six weeks post-operatively. You want to avoid over tightening the binder, but it should be snug.

Bracing: If post-surgical bracing is advised, we will provide you with a local contact for obtaining a brace.

Activity: You are encouraged to gradually start increasing your activity level each day after surgery. You may feel tired after short activity and resting is important. Make sure to listen to your body.

• Walking is encouraged, along with increasing your activity daily as tolerated
• You may do any time of exercise that does not stress your chest muscles when you feel up to it. (i.e. running, stair climbing, sit-ups).
• No lifting more than 10 pounds for 4-6 weeks after surgery
  • For heavy weight lifting, a gradual increase in weight is recommended
• Use your legs when standing from a seated position
• Do not stress your chest muscles
• Deep breathing is encouraged with your incentive spirometer

Stretching: Daily stretching exercise will help with your range of motion and healing process.

Stretching-Pectus.pdf

Sports: After your recovery period of 4-6 weeks you will be able to return to your normal activities without restrictions.

Sleep: Finding a comfortable sleeping position is difficult for some patients after surgery. It may be hard to lay completely flat on your back. Some patients have found sleeping in a recliner or using a wedge pillow after surgery is more comfortable. Sleeping on your side or stomach may be done when you feel comfortable in these positions.

​Diet: You do not have dietary restrictions and can resume eating as you did prior to surgery. You may not feel like eating much for the first week after surgery. This is normal and your appetite will return. The stress of surgery, abnormal bowel moments, and the pain medication all contribute to not feeling hungry. Do NOT force yourself to eat meals. Light snacks such as soup, crackers, toast, pasta and "comfort foods" often work well for patients.

Bowel and Bladder Care: Constipation one of the most common problems after surgery. You will be discharge with prescriptions to help you with bowel care (MiraLax, stool softeners, lactulose). You are encouraged to continue these medications while you are taking the pain medications OxyContin and oxycodone.

Urination should be no different that pre-hospitalization. If you find you are experiencing issues with urination, such as painful urination or inability to urinate please contact your provider.

Scarring: There is not good evidence that Mederma (or similar products) have special powers against scarring. You are certainly welcome to use these products after your incision have healed. Vitamin E can actually be harmful to scars and should not be used either topically or orally (it is fine in a multi-vitamin). If there are any issues with raised scars, the best product is silicone sheeting (Neosporin Scar Care), which can be ordered online or purchased at a pharmacy. Silicone sheeting needs to be worn around the clock for a few months to have an effect. Alternatively, simply rubbing any firm areas of scar tissue with will help to soften and remold the scars. Scars will generally fade from pink to white over a period of a few months to a few years, depending on the person.

Sexual Intercourse: Although many patients are embarrassed to ask about this topic, it is certainly an important issue. After pectus surgery you may resume careful sexual activity around the two week mark. You should be lying on your back, and your partner should be very gentle. You should not have the full weight of your partner on top of you. Use your body as a guide: if it hurts, don't do it!

Follow Up care

Chest x-ray: After surgery the bars must be monitored to ensure stability and correct positioning. Chest x-rays can be done at your local hospital/clinic and do not require travel back to your surgical campus. Upon completion of the test, please have a disc of the images and radiology report sent to your surgeon's office for review. Ongoing x-rays are necessary to ensure NO bar erosion is occurring.

• 6 weeks: front view (PA) and side view (lateral) x-ray of the chest
• 6 Months after your 6 week images
• Annually until the bars are removed

Visits: Follow-up visits with your surgical team are not necessary beyond the initial post-operative visit unless the chest x-ray indicates a need or you have reached your the 2.5 year mark and it is time to discuss bar removal.

Local Provider: Please contact your local healthcare provider for any emergent issues. We can work with your local team to coordinate care. It is important to have a local provider involved with your care before and after your pectus surgery.

Bar Removal

Similar to braces for your teeth, we recommend that the bars remain in for around 3 years.  Most of the time, bars are removed by a simple outpatient procedure.

Learn more about bar removal

This is the final step in the pectus journey. The bars are removed as an outpatient procedure around three years after the original surgery. Patients will arrive two days before surgery for preoperative testing and a consultation.

The recovery time is much shorter, compared to bar insertion. Most patients are comfortable resuming normal activity a few days after bar removal.

Pectus providers at Mayo Clinic

Dawn E. Jaroszewski, M.D. - Arizona

• Emergent Issues (after hours and weekends): please call 480-151-6296
• Non-Emergent Concerns (Monday-Friday 8am -5pm) please call 480-342-0958
• Mail Post-Op Imaging (Radiological Report and Actual CD of imaging) to:
  • Mayo Clinic - Attn: Dr. D. Jaroszewski
  • 5777 East Mayo Blvd
  • Phoenix, AZ 85054

Mathew Thomas, MD - Florida

• Emergent Issues (after hours and weekends): please call 904-953-2000
• Non-Emergent Concerns (Monday-Friday 8am -5pm) please call 904-956-3212
• Mail Post-Op Imaging (Radiological Report and Actual CD of imaging) to:
  • Mayo Clinic
  • Davis 3N, Attn: Dr. Mathew Thomas
  • 4500 San Pablo Road
  • Jacksonville, FL 32224

Mark S. Allen, MD – Minnesota

• If you experience a medical emergency, please call your local emergency response telephone number.
• For other questions, call the Mayo Clinic 24-hour telephone number: 507-284-2511.  Ask to be connected to the following service:  Thoracic Surgery – Allen
• Mail Post-Op Imaging (Radiological Report and Actual CD of imaging) to:

• • Mayo Clinic - Attn: Dr. Mark Allen
  • 200 First Street SW
  • Rochester, MN 55905

Dennis Wigle, M.D., Ph.D.  – Minnesota

• If you experience a medical emergency, please call your local emergency response telephone number.
• For other questions, call the Mayo Clinic 24-hour telephone number: 507-284-2511.  Ask to be connected to the following service:  Thoracic Surgery – Wigle
• Mail Post-Op Imaging (Radiological Report and Actual CD of imaging) to:

• • Mayo Clinic - Attn: Dr. D. Wigle
  • 200 First Street SW
  • Rochester, MN 55905